Interventions for reducing risks and promoting inclusion of street children and young people

Millions of children and young people are estimated to be living and working on streets around the world. Many demonstrate considerable resilience and strong coping skills but continue to be vulnerable to risks. To provide best chances for them in life, services are needed to reduce risks and prevent marginalisation from mainstream society. Thirteen studies have rigorously evaluated 19 interventions such as services to support street-connected children and youth - all in high-income countries. Most have compared therapy-based services versus usual shelter and drop-in services, or versus other therapeutic/health interventions. We found mixed results among these studies but overall findings suggesting that participants receiving therapy and those provided usual services benefitted to a similar level. Future research should consider the benefits of usual drop-in and shelter services, most particularly in low- and middle-income countries, and should focus on street-connected children and young people. None of the studies included participants comparable with street children in low-income countries, who may be on the street primarily to earn a living, or as a result of war, migration or urbanisation. Overall we assessed the quality of the evidence included in this review as low/moderate.

Authors' conclusions: 

Analysis revealed no consistently significant benefit for focused therapeutic interventions compared with standard services such as drop-in centres, case management and other comparable interventions for street-connected children and young people. Commonly available services, however, were not rigorously evaluated. Robust evaluation of interventions, including comparison with no intervention, would establish a more reliable evidence base to inform service implementation. More robust research is needed in LMICs to examine interventions for street-connected children and young people with different backgrounds and service needs.

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Background: 

Millions of street-connected children and young people worldwide live or work in street environments. They are vulnerable to many risks, whether or not they remain connected to families of origin, and despite many strengths and resiliencies, they are excluded from mainstream social structures and opportunities.

Objectives: 

Primary research objectives

To evaluate and summarise the effectiveness of interventions for street-connected children and young people that aim to:

• promote inclusion and reintegration;

• increase literacy and numeracy;

• facilitate access to education and employment;

• promote mental health, including self esteem;

• reduce harms associated with early sexual activity and substance misuse.


Secondary research objectives

• To explore whether effects of interventions differ within and between populations, and whether an equity gradient influences these effects, by extrapolating from all findings relevance for low- and middle-income countries (LMICs) (Peters 2004).

• To describe other health, educational, psychosocial and behavioural effects, when appropriate outcomes are reported.

• To explore the influence of context in design, delivery and outcomes of interventions.

• To explore the relationship between numbers of components and duration and effects of interventions.

• To highlight implications of these findings for further research and research methods to improve evidence in relation to the primary research objective.

• To consider adverse or unintended outcomes.

Search strategy: 

We searched the following bibliographic databases, searched for the original review, from inception to 2012, and various relevant non-governmental and organisational websites: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE and Pre-MEDLINE; EMBASE and EMBASE Classic; Cumulative Index to Nursing and Allied Health Literature (CINAHL); PsycINFO; Education Resource Information Center (ERIC); Sociological Abstracts; Social Services Abstracts; Social Work Abstracts; Healthstar; Latin American Caribbean Health Sciences Literature (LILACS); System for Grey literature in Europe (OpenGrey); ProQuest Dissertations and Theses; EconLit; IDEAS Economics and Finance Research; JOLIS Library Catalog of the holdings of the World Bank Group and International Monetary Fund (IMF) Libraries; British Library for Development Studies (BLDS); Google and Google Scholar. We updated the search in April 2015 for the review update, using the same methods.

Selection criteria: 

This review includes data from harm reduction or reintegration intervention studies that used a comparison group study design; all were randomised or quasi-randomised studies. Studies were included if they evaluated interventions provided for street-connected children and young people, from birth to 24 years, in all contexts.

Data collection and analysis: 

Two review authors independently extracted data and assessed risk of bias and other factors presented in the Discussion and Summary quality assessment (Grades of Recommendation, Assessment, Development and Evaluation (GRADE)). We extracted data on intervention delivery, context, process factors, equity and outcomes, and grouped outcomes into psychosocial outcomes, risky sexual behaviours or substance use. We conducted meta-analyses for outcomes where the outcome measures were sufficiently similar. We evaluated other outcomes narratively.

Main results: 

We included 13 studies evaluating 19 interventions from high-income countries (HICs). We found no sufficiently robust evaluations conducted in low- and middle-income countries (LMICs). Study quality overall was low and measurements used by studies variable. Participants were classified as drop-in and shelter-based. No studies measured the primary outcome of reintegration and none reported on adverse effects.We found no consistent results on a range of relevant outcomes within domains of psychosocial health, substance misuse and sexually risky behaviours . Interventions evaluated consisted of time-limited therapeutically based programmes that proved no more effective than standard shelter or drop-in services and other control interventions used for most outcomes in most studies. Favourable changes from baseline were reported for outcomes for most participants following therapy interventions and standard services. We noted considerable heterogeneity between studies and inconsistent reporting of equity data. No studies measured the primary outcome of reintegration or reported on adverse effects.